So You’ve Decided to Tweet

As the new medical-academic year begins, I'm guessing a bunch of new interns will learn about how great FOAM is, and at the same time, get an orientation lecture on "threats to professionalism." Obviously I think there is a ton of potential benefit to using social media as a medical professional, and here are some of the ways I "maintain professionalism" (read: keep myself out of trouble).

One of my big keys is to not try to "not violate HIPAA" – that's easy and too low of a bar.
The real key is to not piss off the carpetwalkers: I don't want to have to defend myself in a meeting with Risk Management. Instead, I want to maintain a general profile I can defend to my dean and my department chair (and maybe someday to the promotion & tenure committee).

Twitter is a Giant Elevator
My big overall philosophy is that social media is like talking on an elevator. But: my mom, department chair, medical school dean, the patients' family, and a million other people are in the elevator. Obviously that doesn't mean that I'm always banal and polite. Rather, I recognize that people will see what I write and it is always tied to me.

Patient Privacy
Easy version: never talk about real patients.

Slightly tougher but still easy: if I do want to talk about real patients, I change enough of the details so that if the actual patient were to see it, the patient wouldn't recognize that it was them.

Two mistakes people make: date of service and age over 90 are HIPAA-protected PHI. The number one thing I do if I am referencing something that happened to a real patient is that I don't do it the same day (or even the same week).

I never even reference "oh look what happened on my drive to work today" so there can't be a real connection between anything I say and a real patient. And I don't share pictures from work or of patients without all of my ducks in a row (if at all).

On Anonymity
I'm not opposed to being anonymous, but I'm very much intentionally not. This is partially as a check on myself -- I know whatever I say is tied to me. A big part of it is to avoid the fear of people discovering my secret identity.

I'm not recommending anyone be anonymous on social media, but if I were, I would tell all my relevant bosses (e.g. program director, chair). If something serious "goes down," i.e. there's some sort of scandal, and it's a total surprise and secret to everyone, I imagine that there will likely be a big sense of betrayal.

But I don't want to be anonymous, it means you are giving up a lot of the upside. I imagine the benefits are possible but a lot harder if anonymous. Because the bottom line is that there are legitimate career, academic, and potentially financial benefits to being active on social media as a medical professional.

Urine Drug Screen False Positives

Urine drug screens aren't completely useless, but they have a number of limitations. Here is a table where I have compiled all of the false positive causing drugs I could find (pdf):

Update 4/22/2016:
Here are my sources:

I started with this paper which was I originally heard on EM Abstracts (Jan 2011):

Brahm NC, Yeager LL, Fox MD, Farmer KC, Palmer TA.
Commonly prescribed medications and potential false-positive urine drug screens.
Am J Health Syst Pharm. 2010 Aug 15;67(16):1344-50.

Special thanks to Jon Cole from Hennepin who made this fantastic video.

Other sources include:
UMHS Guidelines for Clinical Care May 2009

Standridge JB, Adams SM, Zotos AP.
Urine drug screening: a valuable office procedure.
Am Fam Physician. 2010 Mar 1;81(5):635-40.

Reisfield GM, Haddad J, Wilson GR, Johannsen LM, Voorhees KL, Chronister CW, Goldberger BA, Peele JD, Bertholf RL.
Failure of amoxicillin to produce false-positive urine screens for cocaine metabolite.
J Anal Toxicol. 2008 May;32(4):315-8.

Ly BT, Thornton SL, Buono C, Stone JA, Wu AH.
False-positive urine phencyclidine immunoassay screen result caused by interference by tramadol and its metabolites.
Ann Emerg Med. 2012 Jun;59(6):545-7.
doi: 10.1016/j.annemergmed.2011.08.013

Swift RM, Griffiths W, Cammera P.
False positive urine drug screens from quinine in tonic water.
Addict Behav. 1989;14(2):213-5.

Updates 5/1/2016
Reordered alphabetically
Added lamotragine -> PCP
Geraci MJ, Peele J, McCoy SL, Elias B. Phencyclidine false positive induced by lamotrigine (Lamictal®) on a rapid urine toxicology screen. Int J Emerg Med. 2010 Dec; 3(4): 327–331.

Added a few more -> PCP
Phencyclidine (PCP) Test Systems Executive Summary. Chemistry and Toxicology Devices. FDA
2013 Apr 25, Link.

Get What You Pay For & Pay for What You Get

This post is co-authored by Seth Trueger & Cedric Dark and also appears on Policy PrescriptionsSee also the related post on Narrow Networks (PolicyRx).

Andrew Sprung and I had a great conversation about Republican presidential candidate Donald Trump's claim that premiums are rising (see the Storify below). Our view: premiums are generally flat. There is a lot of variation around this, mostly geographic, and also largely based on whose premiums you're talking about. Comparing premiums from before Obamacare to today’s is like comparing 1995 and 2015 cell phone plans. [caption id="attachment_5826" align="alignleft" width="300"]Source: Lauren (Flickr/CC) Source: Lauren (Flickr/CC)[/caption] Yes, some people who were insured on the non-group market prior to the ACA saw their premiums go up significantly. But this is a meaningless critique. First, the fraction of people who had non-group plans prior to the ACA is (and still is) pretty small - about 5% in 2011 [source: KFF]. Second, remember that most people who have individual plans only have them for a fairly short period of time; most only enroll in a plan for 6-18 months, such as for a few months while searching for a job and until their next employer-sponsored plan kicks in (see this post for example). And while some were happy with their coverage, remember the two most important caveats to pre-ACA nongroup premiums:
  1. What did these plans cover?
  2. Who didn't these plans cover?
The first of these big problems: people who ostensibly had insurance would find that it didn't help them when they needed it, because they hit annual or lifetime benefits limits; certain medical problems or services weren't covered; or, the insurer cancelled their plan when they made a claim. Even in the best-case situation, remember how frustrating it is to deal with actually getting an insurance claim paid.
"If you think government healthcare is bad, wait until Comcast runs it." - Seth
Personal example #1: I (Seth) had cheap private insurance for a few years in med school after getting kicked off my parents plan well before age 26 (Thanks, Obama) and I paid $60+ a month for essentially useless coverage that didn't really cover anything. Fortunately, I never got sick and I only really needed my insurance to satisfy my school’s requirement (and, maybe, piece of mind. But not really). While we don't know how many people were "happy" with their pre-ACA plan, we can estimate. Per Andrew Sprung, about half of the 16% of people in the non-group market now have grandfathered plans... which is roughly 1/2 of 1/6 of 1/20 of the insurance market, so 1 in 240 insurance plans. The second of these major issues that arises when comparing premiums before and after the ACA: preexisting conditions. How many people were completely blocked from getting insurance because of a preexisting medical problem? And relatedly, how many people were either charged higher premiums because of a preexisting condition? Or, were only given a plan that didn’t cover anything remotely related to their preexisting condition? ("You can buy insurance from us but we won't cover surveillance or treatment for a relapse of your Hodgkin's Lymphoma.") Personal example #2: My (Seth’s) wife was previously charged more (plus had to do a ton of frustrating paperwork) for the preexisting condition of "having a pre-cancerous benign mole removed." Remember: private insurance companies aren’t incentivized to keep us healthy; they are incentivized to keep us healthy until we turn 65. While a small fraction of individuals now pay a little more for their premiums, their insurance actually now has to cover stuff; and, they aren't getting a discount by excluding all the people who have serious health problems (or benign moles). Given all these caveats, it's really remarkable that premiums are pretty much flat at all. Let’s consider one last thing. “Premium price" can mean a lot of things. Is it subsidized or unsubsidized? Subsidized premiums are most likely pretty flat, and are what individuals actually pay. Unsubsidized premiums have gone up, but not by as much as people like Trump claim. I'm the first to admit that probably the biggest question the ACA poses is: will premium subsidies simply cost too much? And so far, it doesn't seem like it.
We have a great review forthcoming from Laura Medford-Davis on this issue. Stay tuned! - Cedric
Premium subsidies are simply the price we pay for insuring millions and millions of Americans in a functioning market for non-group insurance. And let’s not forget the quasi-secret but much, much, larger subsidies we already provide to people insured through their employers. We shouldn’t decry subsidies for insurance bought on the market while spending hundreds of billions of dollars subsidizing employer-sponsored insurance.